[104-10222-10042.pdf — page 182]
# STANDARD FORM 78JULY 1948FEDERAL PERSONNELMANUAL CHATTER MI# ED STATES CIVIL SERVICE COMMISSION## CERTIFICATE OF MEDICAL EXAMINATION(Applicant must supply information below to heavy line)(Typewrite, or Print in Ink)1. MR.   MRS.   MISS   Charlotte   (FIRST NAME)   L. Zehrun;   (MIDOLL INITIAL)   (LAST)2. DATE OF BIRTH   January 18, 18893. MALE   FEMALE4. ADDRESS   Sun 14.0 ardens, kayton 3, 01105. TITLE OF POSITION   Statistical Draftsman6. DEPARTMENT OR BUREAU IN WHICH YOU ARE TO BE EMPLOYED   Office of the Secretary   Interior - Division of Geography7. LOCATION   Kashington, D. C.8. ARE YOU NOW LMPLOYED IN THE POSITION SHOWN IN ITEM 5? YES NO. IF YOUR ANSWER IS "YLS" GIVE THE DATE OF YOUR ORIGINAL APPOINTMENT TO THIS POSITION:9. (A) HAVE YOU ANY PHYSICAL DEFECT OR DISABILITY WHATSOEVER! YES NO. IF YOUR ANSALR IS "YES" GIVE DETAILS(1) DOCS THE VETERANS ADMINISTRATION RECOGNIZE SERVICE-CONNECTED DISABILITY IN YOUR CASE? YES NO(C) HAVE YOU EVER RICCIVED DISABILITY RETIREMENT FROM THE U S. CIVIL SERVICE COMMISSION? YES NOSign your name in INK as it appears on your appli- SIGNATURE OF APPLICANTcation in the presence of the physician for purposeof identification.Charlotie L. Zehruna;DOCTOR: All questions on both sides of this certificate and on the lower half of the attached Health Qualincation Placement Recordmust be answered. Before beginning the examination refer to items 9 and 10 on the Health Qualification Placement Record so that youwill have knowledge of the physical requirements of the position to which the applicant is to be appointed. Sign both this certificateand the Health Qualification Placement Record.1. HEIGHT: 6 FEET 8 INCHER WEIGHT __ POUNDS2. EYES:   (A) DISTANT VISION (SNELLEN): WITHOUT GLASSES: RIGHT 20/ LEFT 20/ WITH GLASSES, IF WORN: RIGHT: 2/5 LEFT 20/30   (2) WHAT IS THE LONGEST AND SHORTEST DISTANCE AT WHICH THE FOLLOWING SPECINEN OF JAEGER NO. 2 TYPE CAN BE READ BY THE APPLICANT? TEST   LACH EVE SEPARATELY,WITHOUT GLASSES:WITH GLASSES, IF USED:employees in the Federal classified service as may be roqurstedby the t'ivil Service Commission or its authorized representative.The order will supplement the Executive Orders of May 29 andJune 18, 1924 (Exerutho Order, September 4, 1924).R. 4/ IN. TO 22/ IN.R. 4/ IN. TO 28 IN.L. 4/ IN. TO 22/ IN.LI 4/ IN. TO 28 IN.(C) EVIDENCE OF DISEASE OR INJURY: RIGHT ______ LEFT ______"(1) COLAR VISION IS COLOR VISION NORMAL WHEN CHIRARA OR OTHERCOLOR PLACE TEST IS USED? YES NOIT NOT, CAN APPLICANT PASS LANTERN, YARN OR OTHER COMPARARLE TEST? YES NO3. FAIC. (CONSIDER DENOMINATORS INDICATED HERE AS NORMAL RECORD AS NUMERATORS THE GREATEST DISTANCE HEARD) ORDINARY CONVERSATION:   RIGHT EAR 20/FT LEFT EAR 20/FT EVIDENCE OF DISEASE OR INJURY-RIGHT EAR ______ LEFT EAR ______4. NOSE   *Normal*5. PARA NASAL SINUSES   *Normal*6. MOUTH AND THROAT   *Normal*7. GASTRO-INTESTINAL   *(illegible)*   (A) HISTORY OF PEPTIC ULCER: YES NO IF "YES" IS ULCER: ACTIVE QUIESCENT HEALED   HOW LONG   DATE OF LAST X-RAY.   SYMPTOMS PRESENT, IF ANY (Severity, frequence. eta):   TREATMENT (L'sa apeco under "Remarks" il roeded):8. HETARCLIC DISORDEAS (INDICATE ANY ABNORMALITY OF THE FOLLORING CLANDS BY A CHECK IN THE APPROPRIATE BUX, AND EXPLAIN UNDER "REMARKS).THYROIDPANCREASPITUITARYOVARIAN10-25001-1